A nurse is caring for a patient immediately following endotracheal intubation.
Which of the following actions should the nurse prioritize to assess the patient for complications?
Auscultate lungs for the presence of breath sounds.
Determine that the pulse oximetry is greater than 95%.
Assess baseline level of consciousness.
Assess for the presence of circumoral cyanosis.
The Correct Answer is A
Choice A rationale
Auscultating the lungs for the presence of breath sounds is a priority action following endotracheal intubation. This helps to confirm correct tube placement and assess for complications such as a pneumothorax.
Choice B rationale
While it is important to ensure that the pulse oximetry is greater than 95% to confirm adequate oxygenation, this is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.
Choice C rationale
Assessing the baseline level of consciousness is important, but it is not the priority action following endotracheal intubation.
Choice D rationale
Assessing for the presence of circumoral cyanosis can indicate hypoxia, but it is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Collective bargaining activity at a nearby hospital may be of interest, but it is not directly related to the quality improvement of the unit.
Choice B rationale
Systems that make it difficult for the nurses to do their job directly impact the quality of care provided in the unit. Addressing these issues can lead to improvements in workflow, patient care, and nurse satisfaction.
Choice C rationale
While nurse pay is an important issue, it is typically addressed through human resources or union negotiations, not a unit-based quality improvement project.
Choice D rationale
The number of medication errors committed by another nurse is a serious concern, but it is a specific personnel issue. It should be addressed, but it may not reflect the overall quality of the unit.
Correct Answer is ["10"]
Explanation
Step 1 is to determine the amount of cefaclor in each milliliter of the oral suspension. This is done by dividing the total amount of cefaclor in the suspension (250 mg) by the total volume of the suspension (5 mL). So, 250 mg ÷ 5 mL = 50 mg/mL.
Step 2 is to calculate the volume of the suspension that contains the prescribed dose of cefaclor (500 mg). This is done by dividing the prescribed dose by the amount of cefaclor in each milliliter of the suspension. So, 500 mg ÷ 50 mg/mL = 10 mL. Therefore, the nurse should administer 10 mL of the cefaclor oral suspension per dose.
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